20191247 Ver 1_Shoreline Stabilization_20190917

N. State of North Carolina
C.-
Resources
Department of Environment and Natural Resources '�
Division of Water
Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL QUALITY FORM: SSGP 02-2017
Shoreline Stabilization Application Form
2 0 1 9 1 2 4 7
Three copies of the application (including attachments) and the application fee should be sent to:
If sending via US Postal Service If sending via delivery service (UPS, FedEx,
etc.)
Karen Higgins Karen Higgins
DWR — 401 & Buffer Permitting Branch DWR — 401 & Buffer Permitting Br6104�d'�
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Informatinn
Name:
Mailing
Sectsoc
�QCC111ta!��
Telephone Number:/ao.17Fax Number.
E-mail Address: t o -P �'%�[�J,/�E�rTi`r'5,��Me-, , 0 , G' -q0 -t
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter must be attached if the Agent has
signed this application form. (A form can be downloaded here:
http-J/www.saw.usace.army.miI/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
B. Project Information [15A NCAC 02H .0502(a) & (b)]
1. Attach a vicinity map (i.e. street map) clearly showing the location of the property with
respect to local landmarks such as towns, rivers, and roads.
2. Provide a detailed site plan showing property boundaries and proposed locations of
vegetation clearing, buildings, retaining walls, docks, impervious surfaces, rip rap, excavation
or dredging below Full Pond/ Normal Water Level elevations, and construction access
corridors. You may use the diagram provided at the end of this application form.
FORM: SSGP 02-2017 Page 1 of 3

3. Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale of
some sort- a yard stick, shovel handle, etc.)
4. Location of the property (where work is to be conducted)
County: M on aom-e/'
Lake/ river/ ocean adjacent to property:
Property size (acres):
Nearest Town
Directions to site -
.,"atvvfIf-or T
include road names and numbers, landmarks, etc.:
-2 i 7?> /,V/YS TD Ah.111 l
Latitude (in decimal degrees) Longitude (decimal degrees)
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): %e S%" iLe^?ra- / e;,.e
6. Describe proposed work (include discussion as to how_hardening of shoreline has been
avoided, or why it is necessary): (aur lGln� Cj � S �
7. Will work be conducted from land? From water? ❑
8. Total amount of impacts below the normal pool lake level/ Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
0-P rc� n `'iFT X 200
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
S r X C 00 Fr A"'o rcz n
Temporary impacts (temporary clearing, construction corridor) in_square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50
feet landward to be impacted (number of trees, for instance): Ltl'
11. Signature
Owner/Agent's Signatu [15A NCAC 02H .0502(fll Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4

12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
Lake
(At Full Pond/ Normal Water Level)
1y,O
0I
Full Pond/ Normal Water Level
Shoreline
"Opo p
a
Plan View
Lake
(nr wn vcw7 H«t„af Wam temp Existing Dock
/30 ftx 7ft
Full Pond/ Normal Water Lev
-I reline
2 h. �150 ft.
additi—a clearing
if --ry
E
Plan View
EAT 0 [0
'M k NA I ,
FORM: SSGP 02-2017 Page 3 of 4

lig
`
>
J s
Lake o`, d j
(At Full Pond/ Normal Water Level) m
to =11
b
Side View
U-
...................._ _..._ _ -----_ - — .. _ --- _---------.-.- -
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
l I 'if necessary
Existing bank
10 ft. bank
height �Oa
QO
QUO
Side Vi
jW MPLE
FORM: SSGP 02-2017 Page 4 of 4

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